ThinkProgress reports on the latest census data concerning insurance. There are now 46.6 million people without health insurance, an increase from last year's 45.3 million. I have tried to reproduce the graph below but unfortunately I am having some technical difficulties. Thanks to firedoglake for the update.

Ezra Klein points to an interesting article on the KaiserNetwork.Org that reviews a recent study in the August edition of the Journal of General Internal Medicine. The study discusses the unexpected people who are selected to be health care proxies when individuals are asked by their doctors for emergency contacts and proxies. Some of the findings:

28% of participants selected someone other than their emergency contacts;

One-third of married participants did not select their spouses;

Participants selected their daughters three times more often than their sons and their sisters two times more often than their brothers; and

About one-fourth of participants said that physicians had never previously asked them to select a proxy.

Since I don't have any daughters, perhaps I need to start talking to my friends in more detail about my health care wishes . . . . On a more serious note, I did find the comments on Ezra's blog below the article to be very revealing and informative.

National Public Radio had a thorough report on the recent compromise to permit Plan B to be over-the-counter for those women who are age 18 and over. More information can be found in the New York Times. It reports:

The F.D.A.’s acting commissioner, Andrew C. von Eschenbach, wrote
that he decided that 18 was the appropriate cutoff for sales because
pharmacies already restrict nicotine and cold medicines sales at that
age.

“This approach builds on well-established state and
private-sector infrastructures to restrict certain products to
consumers 18 and older,” Dr. von Eschenbach wrote in a memorandum.

Dr.
von Eschenbach’s predecessor, Dr. Lester M. Crawford, said last year
that science supported giving over-the-counter access of the drug to
women as young as 17, but that he could not figure out how to ensure
that such an age restriction was enforced.

The agency has now
decided that it will depend upon Barr to enforce the rules. Barr’s
chairman, Bruce L. Downey, said in an interview that the company would
rely on pharmacists to abide by the restrictions. Barr will not sell
the pills to convenience stores, and the company will conduct surveys
to measure whether the restrictions are being followed, Mr. Downey said.

According to the Times article, both sides of the debate over Plan B's availability are not happy with this result. Those who wished for over-the-counter access believe that younger women may be injured by having to obtain a prescription for its use and those who opposed Plan B's over-the-counter availability believe that its increased availability will lead to an increase in sexually transmitted disease.

The U.S. government currently spends a phenomenal sum of money on health care by world standards ... [W]hen you're talking about universal health care you're not really talking about increasing the aggregate resources poured into American health care. There's already tons of money being spent on it. You're talking about redistributing the spending somewhat from richer to less-rich people and altering the path through which the money flows.

I'm not a health care expert, but it seems to me:

1) If we want a system that reinforces social equality--everyone in the same waiting room-- that means we need basically the bottom 90% to use the same system. The hardest (i.e. impossible) way to do this is by forcing the affluent to get less care than they are willing to pay for ("redistributing the spending somewhat from richer to less-rich people," as Yglesias tactfully puts it.) The easiest way to do that is to offer subsidized universal care good enough so that the vast majority of the affluent will be content to use it. In other words, you can't just "insure" the poor with bare-bones HMO treatment. This will be expensive.

2) Medical technology will offer more and more complex and costly ways to treat illness. Some of these treatments will work. We want to offer them to everyone, with a minimum of rationing--again, in a system that most of the affluent will also sign up for. The alternative seems to be a system in which the upper middle class lives (because they can afford fancy treatments) and the working poor die. Avoiding this will be expensive.

3) We will still want to encourage future medical research and technological advance--or at least we want to retard it as little as possible. That's why I'm skeptical of some plans for realizing huge cost savings. For example, the government could undoubtedly use its monopsony power to lower the price it pays for drugs--maybe lower the price to something approaching the marginal cost of producing additional pills. It's not at all clear, however, that this is the price we should want to pay, because it does little to fund research and development costs of developing both the existing drug and new drugs. See Michael Kinsley's analysis here. Paying medical providers enough to fund future advances will be very expensive.

This article appeared last week in the New York Times and discusses China's growing mummified body business:

Inside a series of unmarked buildings, hundreds of Chinese workers,
some seated in assembly line formations, are cleaning, cutting,
dissecting, preserving and re-engineering human corpses, preparing them
for the international museum exhibition market.

“Pull the cover
off; pull it off,” one Chinese manager says as a team of workers begin
to lift a blanket from the head of a cadaver stored in a stainless
steel container filled with formalin, a chemical preservative. “Let’s
see the face; show the face.”

The mastermind behind this
operation is Gunther von Hagens, a 61-year-old German scientist whose
show, “Body Worlds,” has attracted 20 million people worldwide over the
past decade and has taken in over $200 million by displaying preserved,
skinless human corpses with their well-defined muscles and sinewy
tissues.

But now with millions of people flocking to see “Body
Worlds” and similar exhibitions, a ghastly new underground
mini-industry has emerged in China.

With little government
oversight, an abundance of cheap medical school labor and easy access
to cadavers and organs — which appear to come mostly from China and
Europe — at least 10 other Chinese body factories have opened in the
last few years. These companies are regularly filling exhibition
orders, shipping preserved cadavers to Japan, South Korea and the
United States.

Fierce competition among body show producers has
led to accusations of copyright theft, unfair competition and
trafficking in human bodies in a country with a reputation for allowing
a flourishing underground trade in organs and other body parts.

Here
in China, determining who is in the body business and where the bodies
come from is not easy. Museums that hold body exhibitions in China say
they have suddenly “forgotten” who supplied their bodies, police
officials have regularly changed their stories about what they have
done with bodies, and even universities have confirmed and then denied
the existence of body preservation operations on their campuses. . . .

Worried about a growing trade in illegal bodies, the Chinese government
issued new regulations in July that outlawed the purchase or sale of
human bodies and restricted the import and export of human specimens,
unless used for research. But it is unclear how the regulations will
affect the factories. . . .

Experts say
exhibitions featuring preserved bodies are now among the most popular
attractions at American science and natural history museums. While the
shows have not appeared at two of the most respected museums — the
Smithsonian and the American Museum of Natural History in New York — they have appeared at major museums in Chicago, Houston and Los Angeles. . . .

The industry is dogged by questions about the origins of the corpses.
Premier says its exhibition uses unclaimed Chinese bodies that the
police have given to medical schools. None of the bodies, it says, are
those of executed prisoners or people who died of unnatural causes. . . .

Officials at the Customs Bureau here in Dalian and the Dalian
Medical University, however, said they had no records showing the
supplier of Premier having acquired bodies and then transporting them
to exhibitions abroad.

“I don’t know where the bodies came from,” said Meng Xianzhi, a spokesman for the university.

Dr.
von Hagens, who opened the first large-scale body preservation factory
here in Dalian in 1999, said he abided by the regulations.

The
fierce rivalry between Premier and Dr. von Hagens’s company, the
Institute of Plastination, has moved to the courts, over everything
from copyright claims to rights to the name “Body World.” They have
each publicly hinted that their rival is engaging in unethical behavior
in acquiring bodies in China.

Although the exhibitions appear to have some educational value, I am not sure they are worth it when the bodies apparently could have been donated involutarily.

Ezra Klein has an interesting post on the Cuban health care system. Apparently some individuals seem to think it is a system to be copied. However, he provides an educational counterpoint to this view:

I'm always skeptical when I hear good liberals waxing rhapsodic about
the wonders of the Cuban health care system. Not only is there a total
dearth of decent data on the country's care, but what does exist tends
to be agenda-driven and ideologically colored. But it is interesting to
read
why Hilda Molina, one of the countries most honored and highly placed
surgeons, resigned her position and became a hated enemy of Fidel's:

In 1989, Dr. Molina realized a longtime dream by
getting the government to establish the International Center for
Neurological Restoration. The center conducted research and treated
Cubans from all walks of life for maladies such as strokes and
epilepsy. Fidel Castro would come for visits, often with foreign
dignitaries in tow. "It was a point of pride that Cuba could have such
an advanced facility," says Dr. Molina, who was rewarded with a seat in
the Cuban Parliament.
. . .

But in the 1990s, the collapse of the Soviet Union, which had
bankrolled the Castro regime, began undermining the project to which
Dr. Molina had dedicated her life. Dr. Molina says authorities ordered
her to begin setting aside more beds for paying foreign patients,
rather than ailing Cubans. "It was all about earning hard currency for
the government," she says.

The entire piece is well worth a read as we wait to see how well Fidel Castro recovers.

The truly terrific and now recently graduated Jim Tomasewski points out this article in the New England Journal of Medicine entitled, "Language Barriers to Health Care," by Dr. Glenn Flores.Here is a brief excerpt:

Inadequate communication can have tragic consequences: in onecase, the misinterpretation of a single word led to a patient'sdelayed care and preventable quadriplegia.1 A Spanish-speaking18-year-old had stumbled into his girlfriend's home, told herhe was "intoxicado," and collapsed. When the girlfriend andher mother repeated the term, the non–Spanish-speakingparamedics took it to mean "intoxicated"; the intended meaningwas "nauseated." After more than 36 hours in the hospital beingworked up for a drug overdose, the comatose patient was reevaluatedand given a diagnosis of intracerebellar hematoma with brain-stemcompression and a subdural hematoma secondary to a rupturedartery. (The hospital ended up paying a $71 million malpracticesettlement.)

In 1998, the Office for Civil Rights of the Department of Healthand Human Services issued a memorandum regarding the prohibition,under Title VI of the Civil Rights Act of 1964, against discriminationon the basis of national origin — which affects personswith limited English proficiency. This memorandum states thatthe denial or delay of medical care because of language barriersconstitutes discrimination and requires that recipients of Medicaidor Medicare funds provide adequate language assistance to patientswith limited English proficiency. In 2000, a presidential executiveorder was issued on improving such persons' access to services.Thirteen states currently provide third-party reimbursement(through Medicaid and the State Children's Health InsuranceProgram) for interpreter services. Unfortunately, most of thestates containing the largest numbers of patients with limitedEnglish proficiency have not followed suit, sometimes citingconcerns about costs. Although the Office for Civil Rights issuedguidelines in 2003 that seem to allow health care facilitiesto opt out of providing language services if their costs aretoo burdensome, Title VI provides no such exemption.

Ad hoc interpreters, including family members, friends, untrainedmembers of the support staff, and strangers found in waitingrooms or on the street, are commonly used in clinical encounters.But such interpreters are considerably more likely than professionalinterpreters to commit errors that may have adverse clinicalconsequences.1,5 Ad hoc interpreters are also unlikely to havehad training in medical terminology and confidentiality; theirpriorities sometimes conflict with those of patients; and theirpresence may inhibit discussions regarding sensitive issuessuch as domestic violence, substance abuse, psychiatric illness,and sexually transmitted diseases.5 It is especially risky tohave children interpret, since they are unlikely to have a fullcommand of two languages or of medical terminology; they frequentlymake errors of clinical consequence; and they are particularlylikely to avoid sensitive issues.1,5 Given the documented risksassociated with the use of ad hoc interpreters, it is of concernthat the 2003 guidance from the Office for Civil Rights statesthat such use "may be appropriate."

Later this year, the California legislature will consider abill prohibiting state-funded organizations from using childrenyounger than 15 years of age as medical interpreters. LelandYee, the California speaker pro tempore, proposed the bill,prompted by his experiences interpreting for his mother and,later, as a child psychologist. The bill requires organizationsreceiving state funding to establish a procedure for "providingcompetent interpretation services that does not involve theuse of children."

Although this legislation may emerge as a state model, as anunfunded mandate, it will have limited power to improve care.Perhaps the time has come for payers to be required to reimburseproviders for interpreter services. The provision of adequatelanguage services results in optimal communication, patientsatisfaction, outcomes, resource use, and patient safety.1,5A 2002 report from the Office of Management and Budget estimatedthat it would cost, on average, only $4.04 (0.5 percent) moreper physician visit to provide all U.S. patients who have limitedEnglish proficiency with appropriate language services for emergency-department,inpatient, outpatient, and dental visits. This seems like asmall price to pay to ensure safe, high-quality health carefor 49.6 million Americans.

The New York Times has an article on the recent decision to loosen regulations on the use of prisoners to test experimental drugs. The article, entitled"Panel Suggests Using Inmates in Drug Trials"and written by Ian Urbina, states:

An influential federal panel of medical advisers has recommended that
the government loosen regulations that severely limit the testing of pharmaceuticals on prison inmates, a practice that was all but stopped three decades ago after revelations of abuse.

The proposed change includes provisions intended to prevent problems
that plagued earlier programs. Nevertheless, it has dredged up a
painful history of medical mistreatment and incited debate among prison
rights advocates and researchers about whether prisoners can truly make
uncoerced decisions, given the environment they live in.

Supporters of such programs cite the possibility of benefit to prison
populations, and the potential for contributing to the greater good.

Until the early 1970’s, about 90 percent of all pharmaceutical products were tested on prison inmates, federal officials
say. But such research diminished sharply in 1974 after revelations of
abuse at prisons like Holmesburg here, where inmates were paid hundreds
of dollars a month to test items as varied as dandruff treatments and
dioxin, and where they were exposed to radioactive, hallucinogenic and
carcinogenic chemicals.

In addition to addressing the abuses at
Holmesburg, the regulations were a reaction to revelations in 1972
surrounding what the government called the Tuskegee Study of Untreated Syphilis
in the Negro Male, which was begun in the 1930’s and lasted 40 years.
In it, several hundred mostly illiterate men with syphilis in rural
Alabama were left untreated, even after a cure was discovered, so that
researchers could study the disease. . . .

Under current regulations, passed in 1978, prisoners can participate
in federally financed biomedical research if the experiment poses no
more than “minimal” risks to the subjects. But a report formally presented to federal officials on Aug. 1 by the Institute of Medicine of the National Academy of Sciences
advised that experiments with greater risks be permitted if they had
the potential to benefit prisoners. As an added precaution, the report
suggested that all studies be subject to an independent review.

“The
current regulations are entirely outdated and restrictive, and
prisoners are being arbitrarily excluded from research that can help
them,” said Ernest D. Prentice, a University of Nebraskagenetics professor and the chairman of a Health and Human Services Departmentcommittee
that requested the study. Mr. Prentice said the regulation revision
process would begin at the committee’s next meeting, on Nov. 2.

The
discussion comes as the biomedical industry is facing a shortage of
testing subjects. In the last two years, several pain medications,
including Vioxx and Bextra, have been pulled off the market because
early testing did not include large enough numbers of patients to catch
dangerous problems.

And the committee’s report comes against
the backdrop of a prison population that has more than quadrupled, to
about 2.3 million, over the last 30 years and that disproportionately
suffers from H.I.V. and hepatitis C, diseases that some researchers say could be better controlled if new research were permitted in prisons. . . .

The Institute of Medicine report was initiated in 2004 when the Health
and Human Services Department asked the institute to look into the
issue. The report said prisoners should be allowed to take part in
federally financed clinical trials so long as the trials were in the
later and less dangerous phase of Food and Drug Administration
approval. It also recommended that at least half the subjects in such
trials be nonprisoners, making it more difficult to test products that
might scare off volunteers. . . .

TalkLeft has some serious concerns about this potential regulatory change and his piece also provides helpful links to the recent federal report "Ethical Considerations of Research Involving Prisoners." Thanks to TalkLeft for pointing me to this article.

During these rather stressful times, cutting off the funding for the federal suicide hotline does nont seem to make much sense. Here is the website discussing the hotline and a plea for readers to help save it:

1-800-SUICIDE is in danger of being shut off or worse falling into the hands
of the Federal Government. With teenage suicide being the 3rd leading cause
of death between 18 to 24 year olds - our government should not be
duplicating prevention efforts but helping fund the many local organizations
and non-profits with proven track records on prevention. In addition our
government should not be in the business having access to this private and
sensitive information!

No other crisis hotline is owned by the federal government! Read
more...

Despite the fact that almost 2 million callers have reached help and hope
over the last 8 years, and a government funded evaluation stating the
benefits of 1-800-SUICIDE, the Substance Abuse & Mental Health Service
Administration (SAMHSA), a division of Health & Human Services, has decided
to create their own government run system where they would have direct
access to confidential data on individuals in crisis.

Click on the link above to find out how you can do more to help protect this resource.

Carson Palmer, the Cincinnati Bengals quarterback who suffered a terrible knee injury at the end of last season, has an organ donor to thank for his re-built leg. The Cincinnati Enquirer reports,

Julie De Rossi spent the last night of her life passing out fliers
for bands she was managing. As she drove home on a Houston freeway, a
BMW traveling at twice the speed limit slammed her from behind.

The
collision hurtled De Rossi's Volvo into a concrete barrier, crunching
the car like an accordion and leaving the 44-year-old mother with only
a faint pulse. She died later that day, the victim of a drunken driver.

De
Rossi didn't become a meaningless traffic statistic in the early hours
of March 17, 2004. An organ donor, she has since helped mend more than
50 people, including Bengals quarterback Carson Palmer, 26, the
National Football League's top-paid player.

The knee that Palmer heard snapping apart after a crushing hit
during January's playoff game is now held together by Julie De Rossi's
Achilles' tendon.

"It's amazing to think that somebody else is inside me," Palmer says.

"You
look at the scar. You stare at it. You rub it. It's given me a second
chance at life. And I'm extremely grateful to this person." . . . . .

When her life was taken, De Rossi left behind much of value. More
than 92,000 people in the U.S. are awaiting organ transplants,
according to Richmond, Va.-based United Network for Organ Sharing.
Viable transplants can include the heart, kidneys, lungs, pancreas,
ligaments, tendons and skin.

Edison, N.J.-based Musculoskeletal
Transplant Foundation, the biggest U.S. tissue bank, eventually
received De Rossi's donations for processing. As is customary, her
tissue was returned to the part of the country where the donation took
place. Her tendon was stored in a specialized freezer at the Baylor
College of Medicine.

On Jan. 10, Palmer was in surgery at Baylor,
and Paulos selected the tendon. He attached it to Palmer's knee joint
using screws that will eventually dissolve.

Carson Palmer has now signed up to be an organ donor himself. Perhaps others will be encouraged to follow his lead. [bm]

The great Ezra Klein points to an article in the Seattle Times that discusses a study reported in the New England Journal of Medicine concerning why people may have problems losing weight. He states their conclusion rather succinctly:

It's been reported in the New England Journal of Medicine that people
attempting to lose weight tend to underestimate the amount they eat by
as much as 47 percent and to overestimate their physical activity by as
much as 51 percent. When scientists at the USDA's Beltsville Human
Nutrition Research Center in Maryland asked 98 men and women how much
they ate in a 24-hour period, they found that 6 out of 7 women
underreported by an average of 621 calories, and 6 out of 10 men
underreported by an average of 581 calories.

Well, I guess people are doing more than just lying to the Department of Motor Vehicles about their weight - looks like it might be time for everyone to start a food journal just to keep us honest. I wonder how much of this results as well from the way that food is packaged and marketed and from a lack of knowledge about serving sizes. I know that I tend to think that I can eat more chocolate mini-bars and still feel that I am not overeating. Indeed, I perhaps would answer a question about my chocolate consumption with a statement that I have had only a few pieces of chocolate when I probably ate a sufficient number of mini-bars to equal two king size candy bars.

Professor Daniel Solove of Concurring Opinions has an interesting post concerning the use of the internet to blacklist plaintiffs who file medical malpractice suits. He states,

"In a disturbing development, websites are emerging to create
blacklists of individuals who file medical malpractice claims.
According to an article at Law.com:

In 2004, a group of Texas physicians launched
DoctorsKnowUs.com. The site listed the names of plaintiffs, attorneys
and expert witnesses in medical malpractice cases. That site did not
make any distinction between cases that ended in plaintiff verdicts and
those that ended in defense verdicts or settlements.

According to the New York Times, a North Texas man had trouble
finding a physician for his 18-year old son after his name was posted
on the site. He had filed a medical malpractice suit after his wife
died from a missed brain tumor, and had won an undisclosed settlement.

DoctorsKnowUs.com was shut down four days after the Times article was published.

A new website to blacklist medical malpractice plaintiffs has emerged, called LitiPages.com. According to the Law.com article:

In the latest effort to enable doctors to shun patients who
sue, an offshore company has launched an Internet site that lists the
names of plaintiffs who have filed medical malpractice cases in Florida
and their attorneys.

The site, LitiPages.com, encourages doctors to consider avoiding
patients who are listed in the database, and it strongly encourages
plaintiffs who have lost their cases at trial to turn around and sue
their plaintiffs attorney. . . .

Unlike the Texas site, LitiPages.com plans to list only plaintiffs
who filed cases that ended in a defense verdict, a settlement, or a
plaintiff verdict on only one count while other counts were dismissed.

The overwhelming majority of med-mal cases that go to trial result
in defense verdicts. A large percentage of claims never go to trial,
and many of those result in settlements. Some experts say that it's not
possible to say that cases are "frivolous" just because they don't
result in a plaintiff verdict.

He goes on to note the lack of websites that list physicians who have been sued for malpractice and states that such a website, if accurate, would not raise the same issues as the LitPages website.

I believe a distinction can be made. Physicians are professionals,
and they have higher duties and responsibilities than the patients they
treat. Indeed, one of the duties of the profession is to police itself,
to weed out the bad apples. Sadly, I'm not sure that the medical
profession does a good enough job of this (lawyers aren't much better
at policing their own profession). In distinction, a blacklist of
malpractice plaintiffs discourages them from exercising their legal
rights and inhibits the legal system from redressing wrongs by errant
physicians. Moreover, even to the extent to which plaintiffs bring
frivolous suits, these are often the fault of the lawyers, not the
plaintiffs.